Pharmacy Services

Prescription Refill

Please complete this form to request a prescription refill from UH Specialty Pharmacy.

First Name

Last Name

Date of Birth

Email Address

Telephone

Confirmation of no change in address since last refill

Prescription name(s) or Rx Number(s)

Have you been ill or hospitalized in the past 30 days or have you had any changes to your medication?

Yes

Are you taking your medication as directed?

Yes

Changes to Allergies? If yes, please explain:

Changes to Medications? If yes, please explain:

New conditions since last clinic visit? If yes, please list:

Questions or concerns for the pharmacist?

Date delivery requested

Do you agree to leave package without a signature?

Yes

I agree to have my co-pay invoiced.

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Download the App. Get Prescription Refills. Or call us to refill at 216-765-2784 or 833-473-3455.

Easy to Get

To download the free RefillPro app on your mobile device, powered by ScriptPro, visit the App Store or Google Play.

Easy to Use

When you’re ready to refill one or more prescriptions, open the app and follow these simple steps:

Choose UH Specialty Pharmacy by entering the phone number: 216-765-2784.
Follow the prompts until you see “Order Submitted Successfully” on the screen.

When requesting your delivery date, please allow two business days. If there are any issues regarding filling your prescriptions or delivery on the requested date, UH Specialty Pharmacy will contact you directly.